I find myself in an educators dilemma regarding feedback in the ED. I’ll try to explain why and please do give me your thoughts.
The first thing I have to say is that I agree with Greg Henry at ICEM2012 in that the amount of positive feedback given to colleagues should exceed the criticism. Greg suggested a 10:1 as a ratio, but as a more reserved Englishman without the gregarious nature of some of my American colleagues I’m running at about 3:1, any more than that and you get put on antipsychotics on this side of the pond. Anyway, to be honest the offering of positive feedback is fine. It makes me feel good, it makes the trainee feel good, and I usually try to do it in public so that everyone know about it. Great, fine, let’s park the positive stuff.
My dilemma comes with the negative feedback, how to feedback when things have not gone well and lessons are there to be learned. How do we go about this and where are the challenges that we need to identify and manage.
Perhaps an example will help.
One of your radiologists calls you to alert you to an X-ray that they think was missed as it looks as though the patient was discharged. The X-ray clearly shows a fracture of the talus so you pull the notes and indeed it was. The patient presented in an intoxicated state having fallen off a kerb and was complaining of an ankle injury. X-rays were taken, reported as normal on the day by the attending doctor and the patient was discharged with crtuches and ankle sprain advice. It looks as though they left the ED that night (5 days ago). So, you do the usual stuff, recall the patient, apologise, refer etc. The patient gets an operative repair and seems to do OK. So, I’m fine with the clinical care, but clearly an error has been made here and we need to do something about it. I guess three things could have happened.
- The doc may not be able to spot a talus fracture due to simple incompetence.
- They looked at the wrong X-ray.
- They only looked at one part of the X-ray (the malleoli as that’s where they suspected the injury.
My question is how to handle the feedback to the doctor who saw the patient? I’ve seen many behaviours over the years in these situations. Interestingly I have seen some seniors not bother to tell the juniors that an error has been made. Usually this is to ‘protect’ the doctor from getting upset about making an error. Can this be right? Almost certainly not as it is important to learn from error, and also to understand how error takes place (which you cannot do unless you explore the circumstances). So how are you going to go about this in a way that promotes learning and development, and what do we want to happen during that feedback process.
I’m going to be controversial and contradictory here as I must admit that in my mind there are number of things that I want to achieve whilst giving the feedback.
- 1. Discuss and understand what happened.
- 2. Discuss what the consequences are.
- 3. Potentially change future behaviour.
- 4. Ensure that this makes them feel bad (really????).
I guess you were with me up until number 4?? Why would I want a colleague to feel bad with feedback? Well, it’s not that I ‘want’ them to feel bad, it’s because I want physicians to care, I want them to understand that our actions and decisions have consequences and that part of that consequence must be for us to be able to empathise and understand the effect of error with our patients. The doctor who does not care, dismisses the error on the basis of other’s failings, who moves on rapidly without pausing for thought worries me greatly…., but on the other hand the doctor who is devastated by hearing about an error, who loses confidence and changes behaviour in an abnormal way is similarly a failure of feedback, learning and development. The point is that there is an inevitability that a bad outcome for a patient will result in the doc involved feeling bad.
So, what are we to do when faced with a question of giving bad news to a colleague. How do we balance the conversation and experience into one that ensures colleagues reflect and pause, without leading them to despair and a feeling of belittlement? I don’t want them to leave thinking that they have been told off, that’s not the point. It’s just that there is a difference between telling people off vs telling them that everything is fine, because everything is not fine and error is a fantastic learning tool. I think learning is most effective when the error matters to the physician. I’m not sure I have this right yet, but these are my top tips.
- 1. Try and feedback near the start of a clinical shift. It is likely that confidence will be affected and it’s good to be able to observe this in the workplace where it can be dealt with. Keep an eye on your colleagues and make sure they are OK. They will probably be ruminating about what has happened and this can affect them in many ways.
- 2. Recognise that the senior person who gives the feedback is unlikely to be the one that the junior will then come to for support immediately afterwards. They’ll usually find someone else first. If I feedback to a junior doc then the perceived power distance (on their part) often makes it feel more like criticism than development (whatever you say). Not sure how to avoid this apart from point 6 below.
- 3. If you can, feedback with a colleague who will also be around on shift. If I’m feeding back to a junior doc I’ll do this with a middle grade doc as well, or at least tell them that an incident has occured prior to the shift. They are often then the person that the trainee turns to for support later that day.
- 4. Follow up in a few days time to ask if they have any more thoughts on the events and even directly ask if it has changed their practice. You will be amazed how often it does, increased referrals, increased second opinions, inrcreased investigations are common after an error.
- 5. Buy a box of tissues.
- 6. Lastly, never underestimate the value of admitting and publicising your own errors amongst your colleagues. We all make mistakes but there is nothing worse than feeling that you are the only one. Build a culture that shares and learns from error and you’ll find feedback easier whichever side of the conversation you happen to be on.
Oh, and the Talus fracture in this case? Well the scenario was fake, it was me who missed it. A busy night when something went wrong, I think I looked at someone else’s X-ray whilst dealing with too many patients at the same time. I got feedback from a colleague, I felt really bad about it (still do), I learned, I got better, I shared.
1800 – tonight we have a short audio interview with one of my colleagues added to the post about getting yourself ready for feedback. Great stuff from Nat.Natalie May on tips to giving difficult feedback